Advanced Counseling Skills that Motivate and Create Change Part 2 Nina Crowley, PhD, RDN, LD
Nina Crowley, PhD, RDN, LD Medical University of South Carolina Bariatric Surgery Program Heidi Diller, RD ReShape Medical
3 Objectives Learn how to: Formulate counseling strategies in response to common issues ReShape patients face Consider using techniques borrowed from patient-centered care models: motivational interviewing, mindfulness, intuitive eating, and the empowerment approach Adapt counseling style to meet the needs of patients struggling to make long term behavior change for weight management Pre-Approved for 1 CPEU! Download certificate on handouts dashboard
4 POLLS
5 Common Dietitian Dilemmas & Approaches to Try I thought my patients weren t supposed to be hungry. Why isn t this working? Try an Intuitive Eating Approach Patient is telling me they are doing everything right and they stopped losing weight. Plateau. Try using a Mindfulness Approach I can t get them to come back. They say they can lose the weight on their own. Try using the Empowerment Approach Do you have curriculum I can use? They asked for meal plans, what do I give them? Try using Motivational Interviewing Approach
I thought my patients weren t supposed to be hungry. Why isn t this working?
7 Intuitive Eating Principles Evelyn Tribole & Elyse Resch - http://www.intuitiveeating.org/10-principles-of-intuitive-eating/ 1. Reject the Diet Mentality. 2. Honor your Hunger 3. Make Peace with Food 4. Challenge the Food Police 5. Respect your Fullness 6. Discover the Satisfaction Factor 7. Honor Your Feelings without Using Food 8. Respect your Body 9. Exercise - Feel the Difference 10. Honor your Health
8 Intuitive Eating Principles 1. Reject the diet mentality Allowing the hope that a new/better/faster/easier diet (or procedure) is out there will prevent patients from being free to re-discover eating intuitively 2. Honor your hunger When someone is not biologically fed with adequate energy (including carbohydrates!) they may be triggered to overeat excessive hunger undermines intentions to eat moderately, consciously 3. Make peace with food The inner dialogue of shouldn t and forbidden food leads to feeling deprived, uncontrollable cravings, and often giving in, overeating, and guilt (don t be that voice) - giving unconditional permission to eat is difficult but liberating (help them) 4. Challenge the food police Moving away from the inner police (or outer police you?) who says you are good for good foods and bad for bad foods according to diet rules is critical to eating intuitively. Attribution not judgment. 5. Respect your fullness Observe and listen for body signals to tell you that you are no longer hungry or uncomfortably full. The balloon will help patients to learn this so that when removed, patients are used to checking in
9 Intuitive Eating Principles 6. Discover the satisfaction factor The eating experience can be pleasurable and satisfying, and often more fulfilling foods take less to feel that you ve had enough. When in diet mentality, you may not question what you want focus is on should. 7. Honor your feelings without using food Comforting, nurturing, distracting and resolving issues without using food is difficult but worth discovering. 8. Respect your body Acceptance of and being less critical of one s body shape is difficult when focus is primarily on weight loss. Don t be the one pushing the weight loss agenda, promote body acceptance! 9. Exercise feel the difference Shifting focus to movement and activity and how it feels (energy vs. calorie burn) is more motivating 10. Honor your health Think about consistency and eating well over the longer term and focus on honoring health, taste, and feeling well rather than perfection and weight loss in the short term
10 IE Application Goal is not hunger avoidance, but understanding and responding to their hunger cues Teach cues for eating and stopping and use balloon as a catalyst Explore reactions to different textures of foods that sit and those that slide Telling patient they aren t supposed to be or do anything sets them up for more diet-rules and dysfunctional eating What if they are hungry? This starts the start shame/blame cycle of failure all over again! Explore their interpretation of head/emotional hunger vs. physical/stomach hunger The idea of not having hunger may be attractive at first but is worrisome
My patient is telling me they are doing everything right and they stopped losing weight. They are stuck at a plateau.
12 Mindful Eating Principles Allowing yourself to become aware of the positive and nurturing opportunities that are available through food selection and preparation by respecting your own inner wisdom Using all your senses in choosing to eat food that is both satisfying to you and nourishing to your body Acknowledging responses to food (likes, dislikes or neutral) without judgment Becoming aware of physical hunger and satiety cues to guide your decisions to begin and end eating
13 Mindful Eating: Am I Hungry? Michelle May - http://amihungry.com/ Part of ancient mindfulness practice Eating with intention of caring for yourself Eating with attention necessary for noticing/enjoying food and effects on your body Process of eating Awareness of physical and emotional cues Recognition of non-hunger triggers for eating Learning to meet other needs in more effective ways than eating Choosing food for both enjoyment and nourishment Eating for optimal satisfaction and satiety Using the fuel you ve consumed to live the vibrant life you crave
14 Mindful Eating: Am I Hungry? http://www.amihungry.com/pdf/mindful-eating-for-bariatric-surgery.pdf Questions to help recognize, understand, and change decisions about eating: Why do I eat? When do I feel like eating? What do I eat? How do I eat? How much do I eat? Where do I invest the fuel I eat? Awareness of each decision point in mindful eating cycle may help patient discover small changes that can make a difference in why, when, what, how and how much they eat, and where they invest their energy
15 ME Application Explore the concept of plateau for them and their expectations Is it that they are trying really hard and expecting more weight loss, linear weight loss? Consider non-weight based behavioral goals What functional goals or life goals motivated them to initiate efforts for weight loss? Ask what doing everything right means to them? Are you promoting an adherence/compliance model where the only option is compliance or noncompliance, or right/wrong? Try concepts from Acceptance and Commitment therapy (ACT is a mindfulness based therapy) to move from avoidance/rigidity to acceptance/flexibility Accept your reactions and be present, Choose a valued direction, Take action While concept is new/difficult, consider an app Am I Hungry? Mindful Eating Virtual Coach App for checking in when you feel like eating, and guiding through mindful eating process
I can t get them to come back. They say they can lose the weight on their own.
17 Empowerment Approach Medical/Surgical model to treat acute conditions Provider is responsible for diagnosis, treatment, outcomes Providers set therapeutic goals (they know best) and do as I say After weight loss treatment, patients have obligation to follow directions of the provider, and believe of compliance outweighs impact of these recommendations on quality of life Results of this model 36% noncompliance to post-surgical treatment regime Empowerment Model Patient-centered collaborative approach tailored to match fundamental realities of care Helping patients discover and develop the inherent capacity to be responsible for one s own life Recognizes that patients are in control of and responsible for daily self-management after procedure, and success depends on the self-management plan fitting the patient s goals, priorities, and lifestyle as well as facilitating weight loss
18 Empowerment Approach Based on 3 fundamental aspects of chronic illness care Choices Patients make choices each day that have greater impact on outcomes than recommendations by health professionals Control After leaving clinic/conversation, patients are in control of which recommendations they implement and ignore Consequences Consequences of decisions accrue directly to the patients, they have the right and responsibility to management weight loss course in way that is best suited to context/culture of their lives
19 Empowerment Approach Collaboration between equals Role of provider Help patients make informed decisions to achieve their goals and overcome barriers through education, appropriate care recommendations, expert advice, and support Providers bring knowledge and expertise about obesity and treatment Frustration with getting patients to change is less when their behavior is not your responsibility Role of patient Be well informed active partners/collaborators in their own care Expertise on their own life and what will work for them Actively collaborating in the decision-making process makes it more likely to achieve outcomes that are identified as important to onself
EA Application Behavioral experiments as a short-term/monthly goal Discuss self-management, psychosocial issues, and coping Experiment eliminates success or failure concepts Patient-selected goal setting with clarity 1. Define the problem 2. Ascertain patient s beliefs, thoughts and feelings that may support or hinder efforts 3. Identify long-germ goals to work towards 4. Commit to making behavior changes that will help to achieve long term goals 5. Evaluate efforts and identify what was learned in the process
21
22 EA Application Show that you care about patient first, weight loss second Start sessions with how they are feeling and how they believe they are doing in reaching their self-selected goals and caring for themselves before jumping into diet/exercise/weight Stress importance of their role in self-management and daily decision making Address patient s agenda at the beginning of the session We have 15 more minutes to spend today, and I want to be sure that your needs are addressed. Are there issues that you would like to discuss? Remember, that in the end, they ARE doing it on their own! Begin the coach-client relationship acknowledging that the visit structure works for some, not all, and that if they move to doing it on their own and it works, great! And if not, it is a safe, judgment-free zone to return!
Do you have a curriculum I can use? I d love to base my education off something else Patient says they want a meal plan. What should I give them?
24 Motivational Interviewing Principles Client resistance is a product of the environment, not an intrinsic behavior The patient and provider relationship should be cooperative and congenial MI centers around overcoming ambivalence The practitioner keeps options open Responsibility rests on the patient Self-efficacy is paramount
25 Motivational Interviewing Approach MI incorporates 5 counseling techniques that help individuals address ambivalence or insecurities surrounding health choices and behaviors 1. Expressing empathy 2. Developing discrepancy 3. Rolling with resistance/ Avoiding argumentation 4. Supporting self-efficacy MI assists the individual to examine his wants, fears, expectations, hopes and inconsistencies, and then how these impact or influence the problems identified
26 1. Expressing Empathy Acceptance facilitates change whereas pressuring patients to change increases resistance Enter the patient s world: What are the patient s concerns? Why is change difficult? What outcomes does the patient want to see? What obstacles are in the way? What is the patient s background? Move beyond just understanding a patient s unique situation to reinforcing your complete understanding When people feel that they are heard and understood all their challenges, desires and fears they will be more open to input from you on advice and wellness
27 2. Developing Discrepancy Evoke their own reasons for and against change, while resisting coercion Creating a stark picture for the patient that pits their current behavior against their present values and future goals/what is important to them Makes the patient more aware of the future results of their decision-making You cannot motivate or instill motivation in them Help patients hear their own motivation
28 3. Rolling with Resistance/Avoid Argumentation People are not resistant to change. They resist being changed. Seeks an avenue to travel together to change Flows with resistance, moving toward closer inspection of patient's mindset Focus on patient s view of problem Resist the righting reflex that we have to actively try to FIX other peoples problems You arguing for change, assuming the expert role, criticizing, shaming, blaming, labeling or being in too much of a hurry increases resistance
29 4. Supporting Self-efficacy The solutions lie within your patients Empower positive feedback & communicate hope Recognize and applaud self-efficacy when you hear it Patients will gain a better belief that the current change in question is attainable Promote goals that the patient actually can achieve - reinforcing ability to change and the sense of accomplishment in doing so Refer to past accomplishments or provide examples of other patients who have become owners of their own change
30 Motivational Interviewing Micro skills Open ended questions force the patient to elaborate on a given thought, topic or feeling Affirmations reaffirm a patient s strides toward positive behavior change instills self-efficacy Reflective Listening deepens levels of understanding and enhance trust between practitioner and patient Summarizing reiterates the recent progress, related concerns, actions, or roadblocks, gleaned from the interaction. *before summarizing, the practitioner should announce that a summary is coming and invite the patient to interject any feedback, including differences in perspective
31 Change talk Mention and discussion of desire, ability, reason and need to change To elicit change talk Ask evocative questions Ask for examples Use extremes Look back & forward Explore goals Use the position ruler Elicit problem recognition Elicit concern & optimism Once you hear it respond! Tell me more about that So given all of this, what do you think you ll do next? What if anything, will you do now?
32 Putting together a change plan (SOAR) Setting goals help your patients decide which goals are important to them Sorting options use the elicit, provide, elicit model and ask the patient to brainstorm on ideas Arriving at a plan assist the patient in thinking through the steps of the plan, difficulties they might face, how they might address these difficulties and how they will evaluate if the plan is working Reaffirming commitment use the position ruler to ask the patient to rate the importance and confidence in following this plan
33 Take Home Messages After this presentation, I hope you learned that: Knowledge does not equal motivation Nonadherence does not mean the patient does not want to change It is the patient s agenda, not yours! I repeat its about them, not you! Match the counseling technique or skill to the patient s stage of change It is not your responsibility to make the patient change or adhere to the plan Learning about intuitive and mindful eating will be valuable long term Ditch the rigid rules, diffuse expectations, and get to know your patients!